theoretical versus pragmatic design in qualitative...

Theoretical versus pragmatic design in qualitative research

Smith, J, Bekker, H and Cheater, F

Title Theoretical versus pragmatic design in qualitative research

Authors Smith, J, Bekker, H and Cheater, F

Type Article

URL This version is available at: http://usir.salford.ac.uk/18361/

Published Date 2011

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JS Nurse Researcher December 2008 1

Nurse Researcher Title: Theoretical versus pragmatic design challenges in qualitative research

Authors Dr Joanna Smith, School of Nursing, Midwifery and Social Work, University of Salford,

Salford, Greater Manchester, M6 6PU, UK E-mail [email protected]

Dr Hilary Bekker, Senior Lecturer in Behavioural Sciences, Institute of Health Sciences,

University of Leeds

Professor Francine Cheater, Professor of Public Health Nursing, University of Leeds

Acknowledgements: We wish to thank M Donovan-Hall, School of Health Professional and Rehabilitation

Sciences, University of Southampton for her contribution to the development of figure 1

which depicts the relationship between qualitative and quantitative methods of analysis.

Key Words: Qualitative research, framework analysis, parent’s experiences, hydrocephalus

Abstract The relative merits of adopting a generic versus theoretical approach to undertaking

qualitative research have polarised qualitative researchers and overshadowed the need

to focus on research that address clinical questions. Drawing on the challenges of

designing a study that explored parents’ experiences of living with a child with

hydrocephalus, we will argue that over adherence to, and deliberations about, the

philosophical origins of qualitative methods such as phenomenology, ethnography and

grounded theory is undermining the role qualitative research could contribute to

evidence-based healthcare, and suggest qualitative methods should stand alone.

mailto:[email protected]�

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Introduction For the novice qualitative researcher, designing an enquiry based study aimed at

investigating how individuals make sense of and interpret their experiences of health

and illness is challenging because of the range and diversity of qualitative methods. In

order to make an informed choice about a study’s design, appreciating the underlying

principles, similarities and differences of the main qualitative methods, and their

application to the topic area being investigated is essential (Ritchie and Lewis 2003,

Morse and Richards 2002). This is not an easy task; first there does not appear to be a

definitive way of classifying qualitative research (Patton 2002). Second, a

preoccupation with debates concerning the underpinning epistemological basis of

qualitative methodology has overshadowed the need to identify research priorities and

develop questions that could enhance nursing practice (Rolfe 1998). Third, the overtly

critical stance of some qualitative researchers in relation to the ‘academic’ standing of

generic approaches to undertaking qualitative research is undermining their value

(Sandelowski 2000).

Although various terms are used to describe qualitative research that is atheoretical

such as ‘generic designs’ (Holloway and Tordes 2003) and ‘descriptive designs’

(Sandelowski 2000), for consistency ‘generic research’ will be used to represent

qualitative methods not underpinned by a specified theoretical perspective. This article

will evaluate the potential benefits of adopting a generic qualitative approach when

designing studies aimed at understanding user and carer perspectives, a key driver

within United Kingdom health policy reforms (DH 2001). This will be achieved by

sharing personal reflections of the challenges encountered when designing a qualitative

study that focussed on parents’ experiences of living with a child with hydrocephalus.

Context Hydrocephalus is a long-term condition normally identified in early childhood

characterised by excess cerebrospinal fluid in the ventricles of the brain. The main

treatment for hydrocephalus is the insertion of a permanent ventricular shunt, which

diverts the excess fluid from the ventricles to the peritoneum. Ventricular shunts have

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high complication rates, particularly shunt malfunction, with most children requiring at

least one shunt revision (Tuli et al 2004). Caring for the child with hydrocephalus

includes ensuring parents’ have the skills to recognise acute changes in their child which

might indicate possible shunt malfunction. The similarity of the presenting symptoms of

shunt malfunction such as headache, vomiting, drowsiness and irritability are the same

presenting symptoms of many childhood illnesses. Consequently children have frequent

admissions to hospital for potential shunt malfunction, which can be disruptive for the

child and family.

These issues, along with a paucity of published research relating to the impact of

hydrocephalus for the child and family, provided the impetus to undertake the study

aimed at exploring and understanding parents’ experiences and perceptions of living

with a child with hydrocephalus. A qualitative design was relevant because qualitative

methods offer ways to gain insights about individual experiences and the construction of

meaning (Patton 2002). Although adopting a qualitative approach was appropriate to

meet the study aims, choosing an appropriate design within the range of qualitative

research paradigms was challenging.

Qualitative research: design challenges Qualitative research is a generic term that refers to group of methods and ways of

collecting and analysing data that are distinctly different from quantitative methods

because of the absence of quantification and statistical analysis. Qualitative methods

are ideal to explore topics where little is known, make sense of complex situations, gain

new insights about phenomena, construct themes in order to explain phenomena, and

ultimately foster a deep understanding of the phenomena (Morse and Richards 2002).

Within healthcare qualitative methods are appropriate for exploring the complexities of

social, economic, political and environmental factors that affect health and well-being.

Research questions that may be difficult to answer by the manipulation of variables

include: understanding patients’ experiences of heath and illness, interactions with

healthcare professionals and services; and organisational cultures and professional

roles (Barbour 2000). In addition qualitative methods can enhance quantitative methods

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particularly clinical trials through understanding patient decisions, explaining unusual

responses to treatments and in the generation of new hypotheses.

Qualitative research is characterised by adopting methods which are interpretative and

focus on meaning (Morse and Richards 2002). Data collection is undertaken in the

natural setting with the depth of the data more important than recruiting large samples.

Data analysis is an inductive process with the explicit aim to describe and interpret the

range of attributes associated with the phenomena being studied (Ritchie and Lewis

2003). Although there are commonalities, qualitative research incorporates a diverse

range of methods with different ontological and epistemological underpinnings,

perspectives and purpose. The diversity of methods results in the researcher having a

range of designs and analytical strategies to choose from. However, this diversity, with

over forty methods having been identified, can be challenging when identifying an

appropriate qualitative method that meets a study’s aims (Tesch 1990).

The challenges of identifying an appropriate qualitative design include distinguishing

between similar methods and becoming over immersed in the epistemological

underpinnings of the chosen method rather than focusing on meeting the study aims

(Sandelowski 2000). An understanding of the main qualitative research designs is

essential in order to ensure decisions are based on an informed choice. One way of

understanding qualitative methods is to consider the overall purpose of the method,

which can be divided into three broad groups; the use and meaning of language,

describing and interpreting participants’ views, and developing theory (Tesch 1990).

Socio-linguistic methods that explore the use and meaning of language include

discourse analysis (Potter and Wetherell 1987) and conversation analysis (Schegloff

2007). Describing and interpreting participants’ views are features of qualitative

approaches such as phenomenology, qualitative content analysis and thematic analysis,

and are common methods for exploring lived experiences. The overarching aim is to

understand the unique meaning and significance of phenomenon as experienced by the

participants. Methods that focus on developing theory are typified by grounded theory

(Glaser and Strauss 1967).

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An alterative way of understanding qualitative research is to consider the methods used

to undertake the analysis, which again can be categorised into three broad groups:

quasi-statistical approaches, the use of frameworks or matrices, and interpretative/

immersion approaches (Crabtree and Miller 1992). This typology reflects the nature of

research in terms of the degree of subjectivity or objectivity by placing interpretive

approaches at one end of a continuum and deductive approaches at the opposite end,

figure 1.

Insert figure 1

Qualitative nurse researchers commonly subscribe to, often to the exclusion of

considering alternatives, the methodologies of ethnography, grounded theory or

phenomenology (Sandelowski 2000). These methods are well established and rooted in

the philosophies of social sciences disciplines such as anthropology, sociology and

psychology. With the increasing value placed on qualitative research within social

sciences disciples there has been refinement and further developments in qualitative

research, both in application and methods (Patton 2002, Ritchie and Lewis 2003). It has

been postulated that as qualitative inquiry evolves and its application across health and

social sciences increases, the methods of undertaking qualitative research should stand

alone without having to be underpinned by, or having a definite allegiance to, a specific

philosophical stance (Patton 2002). As researchers adopt generic approaches to

undertaking qualitative research, predictably, arguments about their relative merits and

comparisons to theoretical approaches have emerged.

The polarisation of qualitative nurse researchers: generic versus theoretical approaches Debates about the relative merits of undertaking qualitative research with or without a

specific theoretical methodology appeared to have polarised nurse researchers.

Traditionalists advocate there is no place for qualitative research that is not driven by a

clear theoretical framework (Reeves et al 2008). It has been implied that qualitative

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research devoid of a theoretical framework results in a lack of methodological coherence

which potentially affects a study’s validity (Morse et al 2002, Rolfe 2004). Conversely

poor understanding, and therefore application, of the theoretical underpinnings of

ethnography, grounded and phenomenology may have contributed to the devaluation of

qualitative methodologies (Baker et al 1992, Paley 1997, Maggs-Rapport, 2001).

However, poor practice is not a justifiable reason for abandoning theoretical

approaches. Theoretically driven research is invaluable in a range of health care

contexts such as explaining organisational cultures, and professional and patient

behaviours (Reeves et al 2008).

Adopting a specified theoretical methodology has been described as an attempt to seek

‘epistemological credibility’ (Thorne et al 1997, page 170) and legitimise nursing

research within a health care culture where quantitative research has traditionally

dominated (Sandelowski 2000, Patton 2002). The practice of combining theoretical

methodologies, often referred to as method slurring, is an example of seeking academic

credence. However, mixing methods often has no clear rational resulting in

incongruence between a study’s aims, design and data analysis (Baker et al 1992,

Paley 1997, Sandelowski 2000). The rigorous application of theoretical methods can

lead to poor representation of participants’ views because final interpretations are often

presented as abstract concepts far removed from the data, leading to misunderstanding

and assumptions within the findings (Clarke 1992).

One of the criticisms levelled at generic approaches is the belief they are not specific

methodologies but methods of undertaking analysis (Braun and Clark 2006). Yet, the

process of generating meaning through grouping data into themes (thematic analysis) is

one of the core skills qualitative researchers require and the bedrock of the majority of

theoretical approaches in particular grounded theory and phenomenology (Holloway and

Tordes 2003). Despite the diversity of approaches and range of terminology used to

describe methods of data analysis, thematic analysis is the most widely used analytical

methods in qualitative research (Braun and Clark 2006). In common with other generic

approaches it has been suggested that thematic analysis should be considered a

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methodology in its own right without having allegiance with qualitative traditions such as

grounded theory (Braun and Clark 2006).

Over immersion in the epistemological and ontological perspectives underpinning the

chosen methodology can result in theoretical perspectives becoming the dominant focus

of the research, rather than the research question posed (Sandelowski 2000). Adopting

a generic qualitative research approach can assist in ensuring data collection methods

and analytical strategies best suit the research question posed rather than trying to fit

the question to a particular philosophical stance (Ritchie and Lewis 2003, Patton 2002,

Morse and Richards 2002). Adopting a generic qualitative approach can enhance the

credibility of a study’s findings because the researcher is more likely to be concerned

with; accurately describing participants’ experiences, staying close to the data, and

ensuring their own interpretations are transparent, compared to researchers who adopt

a theoretically based approach (Sandelowski 2000). The credibility of the research will

depend on; obtaining an appropriate sample, ensuring data collection techniques are

consistent with the purpose of the study and having clear strategies for data analysis

(Sandelowski 2000). Despite the polarisation of qualitative researchers into those for

and those against research without a specific theoretical methodology, there appears

unanimous agreement that the issue of quality is central to the credibility of qualitative

research (Rolfe 2004, Braun and Clark 2006, Holloway and Tordes 2003, Morse et al

2002).

Deciding on an approach that met the research question Considering the debates about the value of theoretical versus generic research added to

the challenges when considering an appropriate study design. The common qualitative

research approaches were considered in relation to their potential application to

understanding the nature of hydrocephalus from the family’s perspectives. In addition,

alternative questions were developed to aid further understanding of the different

approaches to undertaking qualitative research, table 1.

Insert table1

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Reflecting on the underpinning theoretical perspectives of phenomenology, ethnography

and grounded theory culminated in the decision that adopting one of these approaches

would not enhance the study in terms of achieving the study’s aims and objectives. For

example grounded theory is a widely used qualitative approach, based on the

assumption that there are commonalities in the way individuals with similar

circumstances make sense of their social world and therefore was considered a possible

approach for this study. Grounded theory explores social processes that occur within

human interactions and is concerned with the process of the interaction rather than

describing the interaction. Consequently the purpose of grounded theory is principally to

develop theory relating to social process and is particularly relevant when a topic area

has no theoretical underpinnings

Generating theory was not an explicit aim of the study because a range of theoretical

models exist that explain how individuals and families respond to illness or illness

symptoms such as health belief models, family systems theories, and decision-make in

the context of meeting health needs. In addition, grounded theory has been criticised for

not representing the whole picture because examples of participants’ views are

abandoned if not supported in subsequent interviews (Clarke 1992). Representing

views from a range of participants was explicit within the study’s aims because it was

recognised that parents’ experiences may be influenced by: the severity of the child’s

condition usually related to the cause of hydrocephalus, time since diagnosis, the

frequency of shunt complications, and the age of the child.

A decision to adopt a cross-sectional interview-based design, underpinned by the

general principles of qualitative methods, was reached after much reading and reflecting

on the qualitative research literature and discussions with experienced researchers.

Ultimately, the overall aim of qualitative research as a means of describing, debating

and offering insights into a phenomenon by building up a complex, holistic picture was

deemed important. The design was guided by the qualitative methods advocated by

Ritchie and Lewis (2003) and Morse and Richards (2002). The underpinning principles

of their approach to undertaking qualitative research are based on the interrelated

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concepts of interpretivism and reflexivity balanced with pragmatism and transparency,

which can be achieved by:

• Having a desire to understand complex issues and the application of analytical

strategies to find meaning;

• Understanding the importance of participants’ perspectives in the context of their

lives, and representing participants accounts accurately;

• Employing methods that are appropriate to answer the question, rather than fitting

the questions to a particular methodological approach;

• Clearly delineating between researcher interpretations and individual participant’s

descriptions while recognising deeper insights can be gained from synthesising

and comparing participants accounts;

• Reflecting on and acknowledging personal values and beliefs that may influence or

bias the study; • Being open to scrutiny in order to demonstrate transparency.

The qualitative method that underpinned the data analysis was the framework approach

because it was designed primarily for the analysis of cross-sectional descriptive data

(Ritchie and Lewis 2003). The framework approach appears to be gaining popularity

with health care researchers (Pope et al 2000, Mulvaney et al 2006, Prost et al 2007),

because it explicitly describes the processes that guide qualitative data analysis within a

framework of interconnected stages systematic (table 2) (Patton 2002, Pope et al 2000).

Inset table 2

The framework approach is based on thematic analysis, which aims to develop

meaningful themes which represent participants’ accounts (Braun and Clarke 2006).

Data analysis is an interpretive process, where data are systematically searched and

analysed in order to provide an illuminating description of the phenomenon without

explicitly generating theory. Unlike thematic analysis which can result in fragmentation

of the phenomena being studied, the framework approach is not a linear process and

has a greater emphasis on moving back and forth across the data until a coherent

account emerges (Ritchie and Lewis 2003). In addition framework approach appears to

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have greater emphasis on explanatory accounts where themes are constantly refined,

which may lead to the development of a conceptual framework.

Conclusion There is a place for both theoretically driven and generic qualitative research within the

current health care research agenda. Unfortunately, generic qualitative research

approaches that aim to accurately describe a patients experience are often viewed as a

less credible form of research. However, this type of descriptive research is essential if

health care policy is to be met in relation to valuing and understanding users’ and carers’

perspectives of their health care. Debates about the value of theoretically driven

research could be resolved by clearly distinguishing between research that directly

relates to clinical practice and patient care, and research that focuses on generating and

testing theories.

Qualitative research typically employs methods which are flexible and sensitive to the

social context of the phenomena being investigated, recognising that multiple truths

exist. Qualitative approaches are particularly appropriate to explore complex issues for

which there is little known in order to gain new insights and gain a deep understanding

in relation to the individual who has experience of the phenomena. Choosing an

appropriate research approach is challenging and requires the novice researcher to

balance the advantages and disadvantages of the main approaches, and make a

decision based on the specific intent of their own study. Choices will depend on whether

the main focus is within the paradigm of qualitative research and looking through a

particular lens or the focus is health service research and finding the best method to

address the problem. In the later researchers should be confident that qualitative

methods can stand alone without being underpinned by a specific epistemology.

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Figure 1: The relationship between qualitative methods and quantitative analysis

*Interpretative phenomenological analysis

Objective Deductive

Subjective Interpretive

The continuum Quantitative Analysis

Qualitative Analysis

Statistical Analysis

Discourse Analysis

Grounded Theory

Thematic Analysis

Conversation Analysis

IPA*

Content Analysis

Framework Approach

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Table 1: Comparison between three approaches to qualitative research and their application to understanding childhood hydrocephalus from the child and family’s perspectives

Approach

Key features Application to understanding the nature of childhood hydrocephalus from the child and family’s perspectives

Ethnography Philosophical roots in anthropology A relevant framework for describing and understanding a social or culture group or system

Explores the meaning individuals place on the beliefs and values of their cultural group; Considers interaction, actions and events within the system; Data collected through emersion into the system

Children with hydrocephalus can be viewed as a social group. A possible research question in relation to understanding the nature of hydrocephalus through an ethnographical lens could be: Do children with hydrocephalus have the same opportunities for social development as children without hydrocephalus? Adopting an ethnographical approach would not have address the focus of the study which was to understand parents experiences of living with a child with hydrocephalus and specific objectives such as how parents learn about shunt management and associated complications.

Grounded theory Philosophical roots in a variety of disciplines, but primarily sociology A relevant framework for developing theory

Explores social processes that occur within human interactions; Principle aim is theory development rather than describing the social process; Data often collected through interviewing but a range of data collection methods can be used

Grounded theory could be used to explore parent’s experiences of living with a child with hydrocephalus. A possible research question in relation to understanding the nature of hydrocephalus through a grounded theory approach could be: How do parents make decisions about their child’s health needs when their child has hydrocephalus? Adopting a grounded theory approach could address one of the specific objectives of the study in terms of parents’ decision making when their child is ill but would not address the broad aims of the study relating to understanding parent’s experiences. There are a range of theoretical approaches that can be utilised to explain illness behaviours, such as health beliefs, illness roles, adaptation and coping, family systems theories and theories relating to decision making and generating theory was not an explicit aim of the study.

Phenomenology Philosophical roots in a variety of disciplines, but primarily psychology A relevant framework for understanding the lived experiences of participants

Exploration of phenomena in order to understand its unique meaning and significance by those experiencing it; Understanding achieved through language, data usually obtained through interviewing; The researcher describes and attempts to interpret participants accounts of the phenomena

A phenomenological approach could be used to develop an understanding of the unique meaning and significance of living with a child with hydrocephalus as experienced by parents. A possible research question in relation to understanding the nature of hydrocephalus through a phenomenological lens could be: What are the lived experiences of parents who have a child with hydrocephalus? The overall aim of the study, to explore and understand parents’ experiences and perceptions of living with a child with shunted hydrocephalus could be achieved using a phenomenological approach. Implicit within phenomenology is the need uncover the meaning of a phenomena experienced and described by the participants, unstructured individual interviews are usually undertaken to enable the individual to describe the phenomena in term of its meaning to them. This approach would not meet the specific objectives of the study such as how parents learn about shunt management and associated complications, and their decision-making when they seek help for their child if shunt malfunction is suspected.

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Table 2: Overview of framework approach (adapted from Ritchie and Lewis 2003)

Stage Components Data management

1. Verbatim transcription of the interview data 2. Familiarisation of the data through a process of reading and re-

reading the transcribed interview 3. Indenting initial key concepts or themes and sub categories from

which data can be organised 4. Develop a coding index using initial themes and categories 5. Assign data (label/ code) to the themes and categories

Descriptive accounts

1. Summarise and synthesis the range and diversity of coded data by refining initial themes and categories

2. Identifying key dimension of the synthesised data: detecting association between the themes until the ‘whole picture’ emerges

3. Developing more abstract concepts (core concepts)

Explanatory accounts

1. Identify and develop associations/ patterns within concepts and themes

2. Reflect back on the original data as a whole and analytical stages in order to ensure the perceptions of parents are accurately reflected and reduce the possibility of misinterpretation

3. Interpret/ find meaning and explain the concepts and themes and categories

4. Seek wider application of concepts and themes

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